Oscar M. Laudanno, Ronald Estrada Seminario
Squamous cell carcinoma (CE) and adenocarcinoma (AC) represent more than 95% of esophageal tumors; and malignant melanoma and primary lymphomas are rare.
The CE. It is associated with basic ideas deficient in vitamins and minerals, with foods rich in nitrosamines (pickled vegetables, with the intake of alcohol, especially white drinks and is also seen more frequently in mate drinkers with very hot water)
The esophagus undergoes carcinomatous alterations in various predisposing diseases such as Achalasia, Barret's esophagus, chronic esophageal strictures, Plummer-Vinson syndrome and Tylosis.
Among patients with achalasia, treated or not, a 20-year interval is observed between the diagnosis of achalasia and the development of ES:
Chronic strictures can lead to CE. Possibly due to food stasis (increases the contact time of nitrosamines with the esophageal mucosa), esophagitis and epithelial hyperplasia.
Tylosis is a rare autosomal dominant disease that manifests with hyperkeratosis of the palms and soles of the feet and is associated with a 95% incidence of CE
Symptoms and signs
Cancer of the esophagus can be located in the upper, middle or lower third, with symptoms that vary according to location, although the most common location of CE is the middle esophagus. The main symptom is dysphagia ; for dysphagia to appear, the process must affect two thirds of its light, and it is already an advanced cancer. Dysphagia, a conscious sensation of the passage of food through the esophagus, begins gradually, first with difficulty for the transit of solids, then semi-solids and finally liquids; that is, it is a progressive dysphagia. Along with dysphagia, odynophagia also occurs, like a sensation of injury when the solid food passes. This is when the patient points to the place where the food gets stuck and refers pain, anywhere in the sternal region.
Other times the patient has dysglusia , difficulty swallowing, and in this case the cancer may be located in the cervical esophagus or eventually in the distal esophagus. Dysglusia almost always occurs due to the motor disorder generated by the delay of the esophageal transit; its radiological demonstration is called valecular syndrome . The vallecules and periform sinuses become opaque with the barium. These are also seen in upper and lower esophageal sphincter achalasia, and initially in myasthenia gravis.
Dysphagia is accompanied by a striking weight loss in the patient, a fact that will initially guide esophageal cancer, since benign or functional dysphagias, such as achalasia, are generally accompanied by a stable fart. In achalasia there is the so-called paradoxical dysphagia, where the patient takes his first bites well, but then chokes on the liquids. In any case, there are patients who develop cancer in the cardiotuberosity region and, due to secondary destruction of the myenteric plexus, present paradoxical dysphagia, because they developed an organic achalasia or a secondary megaesophagus. It is common for a patient with cervical esophageal cancer to have hypersalivation, due to local irritation from esophagitis. He chokes on sy saliuva.
An adult over forty years of age who begins with progressive dysphagia has cancer of the esophagus until proven otherwise. This is true in more than 70% of the cases. Progressive dysphagia can lead to aphagia , where the blockage is complete. The patient may end up in cachexia.
A dysphagia can also be the beginning of a disease of the mediastinum or cervical, either by compression or by extrinsic invasion, and in this sense the most conspicuous disease is lung cancer. Elderly patients generally present an associated pathology such as a sliding hiatal hernia. Hiatal hernia should not cause dysphagia, so when it exists it is usually caused by stenosing esophagitis or esophageal cancer. Barrett's esophagus, which is a change in the viscera mucosa due to intense reflux esophagitis, leads to the formation of peptic ulcers, due to the progression of the gastric mucosa in the distal esophagus, and predisposes to esophageal cancer. Elderly patients also frequently present functional disorders of the esophagus, such as the spasmodic esophagus, with its tertiary waves,
There are cancers of the esophagus that hide under symptoms such as retrosternal pain and also heartburn ; retrosternal esophageal angina-like pain is produced by reflux with or without accompanying heartburn.
Anorexia is a late symptom of very advanced cancer, as are asthenia and adynamia. Regurgitations are also final as is upper gastrointestinal bleeding or hematemesis. Esophageal cancer can debut with some of its complications, such as fistulous and suppurative esophagotradiastinitis, the final stage of esophageal cancer. Physical examination shows a thin patient, eventually with Troisier (supraclavicular) nodes.
The diagnosis is based on the one hand on the esophageal radiography with double contrast, and on the other on the esophagofibroscopy, with biopsy of the lesion and cytology.
Double contrast x-ray of the esophagus . Allows to perform a thin layer mucosography. The presence of air in the esophagus caused by effervescent powders produces a double contrast with illustrative images, and allows the diagnosis of small lesions, in the form of localized plaques, or incipient ulcerative or vegetating lesions. When the cancer is advanced and takes two-thirds of the light, the radiology will show the typical irregular defiladeros, infiltrative stenosntes, and suprastrictural dilation; in addition to the gross lacunar images or lack of filling and the ulcerations with usually mediastinal fistulas.
Esophagofibroscopy . It allows visualizing the cancerous lesion, generally typical, healthy, bleeding, irregular, ulcerovegetante-infiltrative, in which the biopsies will allow the etiological diagnosis, showing an epidermoid carcinoma or an adenocarcinoma. Cytology is done occasionally.
Computed tomography . Local invasion of the middle esophagus is well demonstrated by CT. And it detects metastasis or distance from solid organs and subdiaphragmatic lymph nodes.
Magnetic resonance . To evaluate mediastinal invasion and liver metastases.
Endoscopic ultrasound . It serves for tumor staging more precisely than CT.